Attitudes toward Telling the Truth to Cancer Patients in Iran: A Review Article.

Background:Patients generally have the right to be informed of their condition, but the debate over the issue of truth disclosure is still present. The attempt of this study is to review the approaches toward truth- telling to cancer patients in Iran. Materials and Methods: This study is a narrative review that included articles published in Iran on attitudes toward telling the truth to cancer patients. The present study extracted data from articles published in PubMed, Science Direct, Scientific Information Database (SID), Magiran, Iran Medex, Google Scholar, Iranian Research Institute for Information Science and Technology with key terms such as truth disclosure, breaking bad news, death awareness and disclosure of diagnosis without any time restriction. Results: Totally, 21 articles including 14 in English and 7 in Persian were selected and reviewed. The results of the study have shown that although treatment team and caregivers are unwilling to disclose the truth to patients, they have a tendency to obtain more information about their disease. Conclusion: As the incidence of cancer has increased worldwide, telling the truth to patients seeking more information about cancer disease would be inevitable, but more studies are required to provide scientific procedures based on evidence for truth disclosure, not the whole, to cancer patients.


INTRODUCTION
According to Medical Ethics, patients have the right to know their medical status 1 . Despite patients' rights about knowing the truth, concealment of diagnosis is a great problem in health care system 2 . Studies have shown that there is an association between patients' information about prognosis of their disease and their treatment preferences 2,3 . All patients with cancer should be told the truth about disease to help them make their own decision about treatment choices. It has been shown that this approach may positively affect patient satisfaction 4 .
There are cultural, professional and emotional obstacles to revealing the truth to cancer patients 5, 6. In Iran, patients with cancer do not have enough information about their disease and treatment choices. Meanwhile, they are not satisfied with the information they receive from their health care providers and have a tendency to obtain more information 7 . It has been shown that a good doctor-patient relationship does not exist and a lack of experience in delivering bad news may contribute to negative emotional reactions and loss of hope in patients 8 .Cultural differences in telling the truth to cancer patients have generated controversy among caregivers and International Journal of Hematology Oncology and Stem Cell Research ijhoscr.tums.ac.ir patients 3,9 .Findings from one culture cannot be applied to other cultures for making decisions, so this study reviewed the previous studies conducted in Iran to find appropriate answers to the following questions:  What are the attitudes of physicians and nurses toward telling the truth to cancer patients?  Do the cancer patients and their families have tendency in facing reality?  What are the consequences of making the patient aware of cancer diagnosis on the treatment procedure?

MATERIALS AND METHODS
This study is a narrative review including published articles (in English and Persian) in Iran on attitudes toward telling the truth to cancer patients. The present study extracted data from articles published in PubMed, Science Direct, Scientific Information Database (SID), Magiran, Iran Medex, Google Scholar, Iranian Research Institute for Information Science and Technology with key terms such as truth disclosure, breaking bad news, death awareness and disclosure of diagnosis without any time restriction. In total, 50 related articles were found; of which 19 were on psychological aspects of cancer. Four articles were excluded from the study due to same content. Articles were available in fulltext format. The type of study, the time of study and the sample size are shown in Table 1.

RESULTS
The survey included 50 articles published in English and Persian on telling the truth to patients with cancer. Totally, 21 articles including 14 in English and 7 in Persian were selected and reviewed; of which 7 were qualitative and 14 were descriptive. The study included physicians (n=767), nurses (n=226), patients (n=3470) and patients' caregivers (n=160).The sample size varied between 10 and 230 participants. Twenty-nine articles were omitted because of duplication and low quality. Data analysis revealed 3 categories: awareness and attitude of treatment team towards truth disclosure, awareness and attitude of patients and their families towards truth disclosure and the effects of truth telling on patients.

Awareness and attitude of treatment team towards truth disclosure
There are two attitudes toward truth disclosure: some physicians presume that cancer patients ought to be informed of their illness, but others conceal the diagnosis from patients. Contrary to East Asian countries, patients are informed of their cancer diagnosis in most western countries 10 . The issue of truth-telling regarding cancer diagnosis is still largely unresolved 7 . Multiple surveys have been conducted on disclosure of information to cancer patients in Iran. In a study conducted by Ghazanfari et al., 85.2% of participants consisted of physicians and nurses (n=51) believed that a patient with cancer should be told the truth, but it is the physician who makes the final decision 11 . According to Izadi et al. (2013), nurses believed in telling patients the truth to increase patient confidence and satisfaction, decrease the number of law suits against nurses and physicians, make informed decisions, maintain and strengthen the relationship between patient and nurse ,fulfill Islamic religious obligations, and obtain patient's cooperation in treatment procedure 12 .In another study, 90% of physicians stated that the cancer patients should be told the truth in the early stages ,while 72 % believed patients should be told in advanced stages of the disease 13 . Kazemi et al. (2010) showed 20% of physicians agreed that cancer patients should be informed of their diagnosis and the terminal nature of their illness 14 . Most of 400 physicians surveyed in one study preferred to disclose the full truth to their patients and 78% believed that providing patients with information would facilitate the treatment procedure and decrease the number of malpractice lawsuits 14 . In contrast, Valizadeh et al. (2014) found that nurses preferred to withhold the truth from patients 15 . They believed that truth disclosure would create tensions, negative emotional reaction and destroy the notion of secrecy 12 . In a survey conducted by Beiraghi et al. (2011), study participants (nurses and physicians) believed that disclosure of cancer diagnosis would be a mistake 16 . Another study on 30 nurses has shown that they use indirect approach to break bad news based on the physician's advice 17 . In a study by Bagherian et al. (2008) on nurses' attitudes (n=120) toward truth telling, the authors found that they were neither willing nor able to train or talk about dying 18 . The majority of physicians (n=20) interviewed in another survey preferred to inform close family members rather than the patients directly. They stressed that patients should be told the truth about their diagnosis by the physician in the vague or indirect language 19 . Another study found that physicians used the patriarchal model or religious beliefs to disclose the bad news. Developing an integrated curriculum with special emphasis on disclosure of bad news and communication skills seem to be essential for physicians 20 .

Attitudes of patients and family members toward truth-telling
Being informed of cancer diagnosis is one of the factors affecting the quality of life cancer patients 10 . Some surveys show that cancer patients should be informed about the nature of the disease to make informed decision, therefore, when the patients are not told the truth they can no longer make informed choices 21 . Sometimes, physicians are asked to withhold the truth from patients to avoid taking away hope or causing them severe distress 10  In many countries, especially in Asia, patients are not told the truth about the diagnosis of cancer, because breaking bad news, if done prematurely, can irreversibly destroy the patient's hope. In such societies, family members make decision without the patient's input 5 . In a study of Shahidi et al. (2007), the majority of family members were of the opinion that the patients are too frail to know the truth and were opposed to telling the diagnosis to the patients 26 . In another study, family members believed that patients should be told the truth gradually during stages of therapy and based on their psychological state. According to physicians and nurses, family members are the main obstacles to revealing the truth to cancer patients 17 .

The effects of truth telling on patients
The diagnosis of cancer can be overwhelming physically, emotionally, or psychologically not only for patients but also for their families 27 . A survey on cancer patients (n=20) showed that they experienced the state of shock after being informed of diagnosis 28 .Tavoli et al. (2007) performed a crosssectional study to assess anxiety and depression in patients (n=142)with gastrointestinal cancer 29 . Anxiety score in patient who were aware of their diagnosis was 9.1, while it was 6.3 in patients who were not aware. Higher score of depression 1,10 was also observed in patients who were told the truth compared to those who were not told 9,10 . The study showed that patients who were informed of their diagnosis had higher levels of anxiety and depression 29 .
The study of quality of life in patients (n=129) with lung cancer, 23% were aware and 77% were unaware, showed no significant difference in social performance, pain, emotional reaction, social isolation and physical activity between the two study groups. This study also noted that sleep disturbances were more common among patients informed of their diagnosis, but, totally, no statistically significant difference was found in quality of life between the two groups 30 . A study conducted by Tarighat et al., (2006) showed no statistically significant association between anxiety / depression and awareness of diagnosis although 30% of patients had anxiety and 17% had depression 7 . The outcomes of the study by Seyyed Rasouli et al. (2014) revealed that there was a discrepancy between positive perception of prognosis and incurable nature of cancer in affected patients. Meanwhile, positive perception caused them to experience a deeper spiritual level. There was a statistically positive correlation between the perception of prognosis and spiritual health among cancer patients 31 . Today, in many countries, patients are fully informed about their true diagnosis, but truth disclosure is not a common practice in Eastern countries 5 .It seems that truth disclosure has a different pattern in our country. Findings have shown that most of patients and nurses have positive attitudes toward truth disclosure 13 . They believe that truth telling can facilitate the process of treatment in cancer patients 32 . Recent studies have shown that although the trend toward full disclosure is increasing in many countries, especially in Asia 20,21 , many healthcare providers find it difficult to break bad news to patients or their family members. But when they were asked to tell the truth, they preferred to use indirect strategy and vague or ambiguous language 15 to deliver bad news 20 .
The majority of physicians withhold the truth from the patients and give information to family members due to worries about negative impact of diagnosis on patients, cultural condition, lack of time and family's wish to do so 7,11 . There is no detailed guideline on information disclosure in Iran, showing that although truth disclosure is an important basis for effective communication health care providers find it difficult to disclose the diagnosis of cancer to patients 29 . Personnel have not been trained how to tell the truth and providing curriculum with emphasis on appropriate transfer techniques along with communication skills have been offered for physicians 20 . The family members of Iranian patients believe that diagnosis disclosure will cause the patient's condition to deteriorate 26 so, they are opposed to telling diagnosis to the patients and try to make decisions instead of patients 5 . They believe that patients should be told the truth gradually during stages of therapy and based on patient's psychological state 16 and they are concerned that the patients are too frail to know the truth 5 . However, the results of studies have shown that disclosure of diagnosis has no impact on hope and quality of life in cancer patients 29 . As the patient's individual autonomy is not considered and the family is given priority in Iran, it is still common for the diagnosis of cancer to be concealed from the patients like most Asian countries. Studies show that cancer patients are dissatisfied with the amount of information they receive 7,10 and approximately half of cancer patients are informed of their diagnosis 33 . Meanwhile, they prefer to be told the truth by the physician and seek to have information disclosed to them first 10 . It is suggested that the disclosure of cancer diagnosis be done by a physician and in the presence of the family members 23 . The studies have also revealed that informed patients may be involved in treatment decisions as well, which improves the patient's quality of life 10 . Moreover, the most appropriate person to tell the patient the truth and relevant information is the physician 7,10,23,26 . Patients have the right to be fully informed about their diagnosis or prognosis and progress of treatment. Findings show that most of International Journal of Hematology Oncology and Stem Cell Research ijhoscr.tums.ac.ir cancer patients, directly or indirectly, will be informed of their diagnosis and the nature of their illness 28 .

CONCLUSION
It is helpful to remove the emotional barriers to give the patients the information they desire to know about their diagnosis and it seems that cultural background and the way patients are informed of an initial diagnosis of cancer have a dramatic effect on the quality of life. In order to reduce the physical and emotional harm in truth disclosed patients, it is necessary to train staff, use new treatment methods and coping techniques to deal with the unpleasant side effects. Results of many recent studies have shown that caregivers are unable to tell the truth to cancer patients because of inadequate education in communication skills and patients are not provided with sufficient information about their diagnosis and process of treatment.

ACKNOWLEDGEMENT
Our special thanks to the Shariati Hospital for supporting this study.